American Psychiatric Publishing
A Division of American Psychiatric Association

Please allow up to 4 weeks for processing. Request will be processed in the order that they are received.

SECTION I. Contact Information:

* Name of Person Making the request:

Name of Company or Organization:

* Address Line 1:

Address line 2:

Address line 3:

* City:

State:

Postal Code:

* Country:

* Email Address for Contact Person (MUST be Vaild):

Telephone Number for Contact Person:

Facsimile Number for Contact Person:

Are you the author of the material you are requesting?

YesNo

Are you a member of the American Psychiatric Association?

YesNo

SECTION II. Bill To Information:

If you would like your invoice to be addressed to a different recipient, please enter that information here:

Name of Company or Organization:

Attention to:

Address Line 1:

Address line 2:

Address line 3:

City:

State:

Postal Code:

Country:

SECTION III. Material to be Reproduced:

Journals:

Journal Name:

Issue Volume and Year:

Complete Article Title:

Author of Article:

Sections, Figures, Tables, or Images to be produced (List and Specify Page numbers):

Are you requesting use of entire article:

YesNo

Books:

Book Title:

Author:

Year Published:

Sections, Figures, Tables, or Images to be produced (List and Specify Page numbers):

For DSM-5 Criteria Requests (List Criteria):

For DSM-5 Requests:

Uses needed, from the list below, must be clearly stated in the request. No blanket or derivative rights will be granted.

A document must be attached to the online permissions request form showing the tables as they will be reproduced in your publication. DSM material must match the source exactly, with the exception of style and format changes.

Each table must show the copyright notice: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

Please note that for DSM-5 requests, we will only grant up to 50% of the total number of diagnostic criteria in the book.

SECTION IV. Description of Your Proposed Product:

Your Product Type:
Book, or Chapter in a bookJournal ArticleContinuing Education Course. Number of Attendees:Seminar, presentation or workshop. Number of Attendees:Product Monograph. Number to be distributed:Newsletter. Number of recipients:Classroom Use. Number of students:Dissertation or ThesisDisability RequestOther (Please specify):

This section is for requests to license Diagnostic and Statistical Manual of Mental Disorders (DSM) material in an electronic health record or other specialized medical or billing software product. Reproduction of DSM alone is not permitted. Licensed product must contain value added information.

For Clinical Trials Requests Only: Will you require specialized customization of the file for your clinical trial?

For SCID-5-CT (Clinical Trial) and SCID-5-RV (Research Version) Requests Only: Type of file that you would like to receive:

Non-modifiable PDF fileModifiable Word File

SECTION VII. Acknowledgements and Signature:

I acknowledge that submission of this request for permission or receipt of a permission fee
quote does not constitute permission, and that any use of any copyrighted text or images owned by
APA or APP is unauthorized unless and until I am in receipt of a signed permission letter, electronic
product license agreement, or email.

I further acknowledge that my proposed use may be such that I may be required
to enter into an Electronic Product License Agreement in APA or APP's sole
discretion.

I further acknowledge that if any usage or administrative fees are assessed by
APA or APP, the signed permission may be withheld until such fees are paid.

Please ensure that the form is completed in its entirety. Incomplete forms may delay processing of your request.

Types of uses that are not granted:

Use of material in mobile device applications such as ipad, itouch, iphone, android, blackberry, or any other devices

Use of DSM material in self-diagnosis

Use of DSM trademark

Reproduction of American Psychiatric Association and American Psychiatric Publishing logos